1. Field of the Invention.
This invention relates to a documentation system and method, and more particularly to a medical history documentation system having a recording apparatus which is used, in the preferred embodiment, by a writer to record in encoded indicia verbal information communicated by a healthcare person to the writer during a physical examination of a patient. The verbal information conveys at least one of the patient's current medical condition, the patient's physical condition, the patient's diagnosis and the patients treatment plan. The medical history documentation system can be either a manual system, a computerized system or a combination of a manual system and computerized system. The method includes a step of comparing the recorded data with the encoded indicia recorded by the writer on the recording apparatus to insure accuracy and validity of the relevant information. The method also includes a step of verification wherein the results of the comparing step are verified upon completion to insure that proper comparison decisions have been made. This provides a validation step for quality assurance, legal and medical purposes.
2. Description of the Prior Art.
Historically, healthcare professionals, such as doctors, nurses and other medical personnel, personally record medical information for a patient using personal handwritten notes or on forms. Such patient information is developed during discussions with and the physical examination of a patient. The forms and/or patient reports generated from the forms and notes are typically stored in patient's history file.
In medical offices and clinics, a patient is typically required to complete a questionnaire which discloses personal information about a patient, including background medical information and pre-existing medical conditions. The questionnaire may also establish a patient's current medical condition. A patient's history file is opened and contains the completed questionnaire along with other documents.
As part of the physical examination, the healthcare person makes a determination as to the medical condition of a patient and this is generally referred to as the Patient Diagnosis. Also, the healthcare person makes a determination as to how a diagnosed medical condition is to be treated medically and this is generally referred to as a Patient Treatment Plan.
When a patient is physically examined by a healthcare professional, the results of the physical examination are typically recorded personally by the physician or healthcare professional entering the information manually onto a form which is then placed in the patient's history file. Also, it is common practice for the healthcare person to make hand notes during the patient's physical examination. The hand notes are later used by the healthcare person for personally dictating a patient's report. The dictation is then transcribed, reviewed and signed by the healthcare person who conducted the patient's physical examination.
The practice of dictating and transcribing is widely used to record information in the medical field. Healthcare professionals have been increasingly burdened by the need to document every encounter with patients. Physicians must record information about each patient's office visit, diagnosis, suggested treatment and prescription given. In addition to recording patient's information, physicians must fill out forms for submission to insurance companies and provide information to regulatory agencies. Physicians spend a significant portion of their work day gathering and dictating the needed information for each record or form. Further, a physician must maintain a staff to transcribe the information into reports and fill out required forms.
There are several medical history documentation systems known in the art which are intended to more efficiently and effectively gather and/or document medical information for a patient.
U.S. Pat. No. 4,428,733 discloses an information gathering system used for obtaining medical information from a patient. The system has one or more question sheets bearing a set of questions, usually medical questions written in the language of the patient. A separate answer sheet is provided, upon which the patient provides answers to the questions. The answer sheet has information concerning each possible answer. The information on the answer sheet may be in a different language than the language of the question sheet. A mechanism is preferably provided for positioning and holding the answer sheet in a predetermined position relative to the question sheets to enable the patient to see the information on the answer sheet as well as the questions.
U.S. Pat. No. 4,221,404 discloses a medical history record filing system which includes a plurality of attachment sheets for holding medical test records and a plurality of medical record sheets.
Each medical record set includes a plurality of separable portions and at least one of the plurality of separable portions is adapted to be attached to one of the attachment sheets. The record sets and the attachment sheets are color coded to indicate the type of medical test that is to be performed and recorded. The separable portion of the medical records is adapted to be attached to a medical record attachment sheet and has provisions for locating the separable portion in a chronological order on the medical record attachment sheet. Each medical record set has provisions for the physician to personally indicate or record the type of tests desired that are to be conducted, the urgency of the request and other pertinent information. In addition, each medical record set has provisions for the laboratory or a person who is analyzing the test results to record test data. Provisions related to the test desired are separated vertically from the provisions related to the test results. The separable portions of the medical record sets are so designed that when a series of them are attached to the attachment sheet only the test results and related information are normally visible on the medical record attachment sheet. One or more medical record attachment sheets and the associated portions of the medical record set can be located in one file folder.
U.S. Pat. No. 3,913,118 discloses a process and apparatus for accurately recording medical and personal information obtained from a medical patient or a prescription customer. The purpose of the process and apparatus is for expediting accounting and bookkeeping procedures related to the medical treatment or prescription services furnished the patient or customer. A transparent matrix has pre-printed thereon in permanent ink portion of a form for recording information to be submitted for payment to a medical program for professional services rendered to the patient or member of the program. The matrix also includes a means forming a pocket thereon for receiving and holding an identification card or other information bearing form, such as a prescription order or the like. The pocket holds the form in position relative to the pre-printed material on the matrix such that the identification information appears through the transparent matrix at a prescribed location relative to the remainder of the form. The so assembled matrix having the form in the pocket is then copied on a copying machine producing a reproduction of the matrix and form as a document containing patient's specific information for use in accounting and bookkeeping purposes.
U.S. Pat. No. 4,991,091 discloses a self-contained apparatus used personally by a physician during patient examination. The apparatus is battery operated and can be reprogrammed to alter or modify examination information or produce a permanent record of examination results. The apparatus includes a penboard which includes microprocessor based controller with internal memory having prestored thereon sets of specific examination indicia which are displayed by liquid crystal displays ("LCDs"). The patient's name is displayed on an LCD. Associated with the specific examination indicia are one or more light emitting diodes ("LEDs") and corresponding bar codes which represent permanently pre-printed indicia representations.
General information diagnosis categories are identified by suitable words such as "Vital Signs". Also, LEDs and bar codes are provided for general examination and treatment categories such as, for example, "Chemistry Profile". The bar codes are used with a light pen for optically identifying the corresponding category and the LED adjacent to each category indicia are illuminated for indicating the category selected by the physician.
The controller includes suitable memory for storing patient examination information, for controlled programming of the operating panel and for down loading data to a central computer. Input to the microcontroller is also provided by a light pen that is manipulated by the physician for scanning one or more bar code panels.
The concept is based on the examining physician personally using the penboard, light pen and microprocessor during the examination procedure to record medical information.
U.S. Pat. No. 5,267,155 describes a document generation system which automates the documentation process in the medical field. The system provides a computer based documentation system incorporating a retrievable database with a menu driver and graphic window environment. The documentation system utilizes previously defined document templates or "boiler-plates" to manage Patient Reports and includes user interface for use in selecting phrases to be inserted in the template.
The system contemplates that the physician personally conducts a patient examination and either generates personal notes which the physician can use later for dictation or the physician personally fills out a checklist.
In this manner, the physician reports of the patient examination can vary for each patient. The input for the report is prepared directly by the physician and can contain any number of variable responses. Each variable response may include different options, such as options on a menu of a computer. The physician can then personally modify and customize the report document throughout by inserting words into the generated document with the use of an integrated word processor.
When the physician personally completes a checklist, another individual can generate the desired document from information checked off by the physician on the checklist.